Corresponding author:
Salas-Pacheco José L. MD, MSc
José Luis Salas Pacheco
Cardiology department, Centenario Hospital Miguel Hidalgo, Aguascalientes, México
Ferrocarril avenue, Alameda. Aguascalientes México. Zip code: 20259
mail: jolsalp@gmail.com
telephone: 449 994 6720
fax: none
ABSTRACT
The COVID-19 pandemic decreased the hospitalizations rate for acute coronary syndromes. The origin was multifactorial. In parallel, the incidence of mechanical complications after acute myocardial infarction increased. Is presented the case of a 54-years-olds female with COVID-19 and acute anterior myocardial infarction, apical aneurysm, and interventricular septal rupture. The surgical repair consisted of ventriculoplasty, septal rupture closure with a pericardial patch, and it was impossible to perform coronary revascularization.
VENTRICULAR SEPTAL RUPTURE AFTER ACUTE MYOCARDIAL INFARCTION ASSOCIATED WITH COVID-19
One of the main presentations of COVID-19 is thrombotic phenomena, including acute coronary syndromes. Acute ST-segment elevation myocardial infarction can present a broad spectrum of manifestations and a higher incidence of complications. Mechanical complications of acute myocardial infarction (AMI) are associated with a mortality rate greater than 80%.1 The four clinical scenarios of mechanical complications are: ventricular septal rupture (VSR), severe mitral regurgitation secondary to papillary muscle rupture, left ventricular free wall rupture, and ventricular aneurysm formation.2During the COVID-19 pandemic, increased incidence of acute MI complications was observed, as well as a significant delay in percutaneous coronary intervention.3-4
Clinical case
A 54-years-olds sedentary woman, former heavy smoker, presented to the emergency department with 36 hours history of atypical chest pain. She still had precordial pain, blood pressure 90/70mmHg, heart rate 89 bpm, and jugular ingurgitation on admission to the emergency room. Chest auscultation revealed a left parasternal holosystolic murmur, in addition to generalized crepitant rales. Electrocardiogram (Figure 1) in normal sinus rhythm, QS complex, and ST-segment elevation from V1 to V6 and ST-segment elevation in DII, DIII, and aVF. High sensitive troponin I of 77.8ng/mL (upper normal limit 0.034ng/mL) and PCR for SarsCov-2 positive in nasal exudate. The echocardiogram showed multiple apical perforations in the interventricular septum with left-to-right shunt, Qp-to-Qs ratio 2.6:1, an apical aneurysm, left ventricular ejection fraction (LVEF) of 17%, restrictive left ventricular filling, and right ventricle dilatated and dysfunctional (Figure 2). Coronary angiography showed the proximal segment of the left anterior descending artery with heavy thrombus burden, complete occlusion with TIMI Flow 0 (Figure 3). Angioplasty was not performed. Given the patient’s condition, the heart team decided to surgically close the VSR, which was carried out ten days after admission. The surgical procedure consisted of placing a pericardial patch on the left ventricular side of the septum and ventriculoplasty with apical aneurysm resection (Figure 4). Myocardial revascularization was not possible science the susceptible artery irrigated thinned and aneurysmatic myocardial tissue. Post-surgical echocardiogram showed no residual shunts, severe ventricular systolic dysfunction with LVEF of 20%, and a residual apical aneurysm. Vasopressor and inotropic drugs were gradually discontinued, and mechanical ventilation was successfully weaned. The patient was in NYHA functional class II at hospital discharge, and guideline-directed medical therapy for heart failure was initiated.
Discussion
Although substantial advances have been made in the early management of AMI, the COVID-19 pandemic trigger delays in treatment and an increase in acute mechanical complications. In the post-revascularization era, mechanical complications incidence decreased to 0.3%; however, during the last year, a surge was observed due to SARS-CoV-2 health emergency.4-5 COVID-19 induces a systemic inflammatory status and severe pulmonary complications that directly impact morbidity and mortality. The viral infection also involves the cardiovascular system causing a broad spectrum of manifestations, ranging from asymptomatic myocardial injury to severe myocarditis with heart failure, arrhythmias, venous thromboembolism, and acute myocardial infarction.3-5 The contingency by the SARS-CoV-2 pandemic originated a worldwide decrease in hospitalizations due to acute coronary syndromes, superior to that expected for seasonal variations previously described.5 Multiple factors increased the late arrival to healthcare services of patients with acute coronary syndromes; fear of acquiring coronavirus infection, the collapse of health systems, and diagnostic bias. This results in delayed reperfusion therapies and a resurgence of mechanical complications of AMI.6-7 Transthoracic echocardiography is the first-line diagnostic modality of VSR; it allows shunt localization, assessment of hemodynamic repercussion, and identification of associated complications. However, transesophageal echocardiography has superior diagnostic performance. Surgery is the treatment of choice. Early intervention is one of the factors that most influence the prognosis.
Conclusions
AMI’s delayed care associated with COVID-19 significantly increases mechanical complications, morbidity, and mortality from non-respiratory causes. Although COVID-19 new cases are currently declining thanks to implementing mass vaccination programs and social distancing strategies, it will be necessary to implement strategies that encourage a timely diagnosis.
Bibliography
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Figure 1. Electrocardiogram shows normal sinus rhythm, QS complexes, and ST-segment elevation from V1-V6 and DII, DIII, and aVF.
Figure 2. Transesophageal echocardiogram. The upper panel shows mid-esophageal long axis views with an apical aneurism. Lower panel, D and E: show deep-transgastric, 0 degrees view with apical interventricular septum complex rupture and left to right flow with Doppler color. F: out-off plane mid-esophageal long-axis view showing left to right flow with Doppler color (yellow arrow). LA: left atrium; LV: left ventricle; RV: right ventricle.
Figure 3. Coronary angiography. Left: Thrombotic occlusion of the proximal segment of the anterior descending artery, with TIMI 0 flow (yellow arrow). Right: The vertical segment of the Right coronary artery shows eccentric, 40% obstruction, with TIMI 3 flow.
Figure 4. Transoperative exposure of interventricular septal rupture. A: Exposure of the ventricular cavity whit complex septal rupture (yellow arrow). B and C: Pericardial patch placement in the ruptured apical interventricular septum (black arrow).